Q & A:Prescribing an Atypical Antipsychotic for a Young Patient with AN

Q. I know that atypical antipsychotics have been used in adults to treat anorexia nervosa (AN). But, is this approach effective for younger patients? (B.L., Des Moines, IA)

A. A team of clinicians at the University of Tokushima School of Medicine, Tokushima, Japan, recently reported successfully treating a 10-year-old boy with AN (71% of ideal body weight for height) with long-acting risperidone injections (Clinical Psychopharmacology and Neuroscience. 2014; 12:65). The boy had a 1-year history of restrictive eating disorder, and was agitated during meals. He showed body image distortion and obsessive fears of being fat, but no depressive mood, hallucinations, or delusions were reported. His physical examination was normal except for emaciation. Although enteral feeding led to a weight gain of 7 kg, the boy became agitated during enteral feeding and continued to refuse to eat. The authors initially started the boy on olanzapine to manage his body image distortion and agitation during meal, but discontinued this drug because of fears of over-sedation.

The authors next turned to use of risperidone, 1 mg per day. All signs of agitation during enteral feeding and complaints based on distorted body image disappeared. After 1 month, the boy started eating meals again. No side effects were seen and the boy’s growth was good in the month after the risperidone was begun. The drug was stopped by providers after 2 months and later stopped again by the patient, each time associated with relapse. On the other hand, a well-designed double-blind, placebo-controlled pilot study of use of risperidone in adolescents with AN showed no benefits in teens with AN during weight restoration (Hagman & colleagues, J Am Acad Child AdolescPsychiatry. 2011; 50:915).

Using atypicals to treat AN in adolescents includes the same challenges seen with adults. First, it appears from many trials with the atypicals that many, perhaps most, people are reluctant to take them, perhaps due in large part to fear of side effects such as weight gain (Norris et al., Eating Disorders. 2010; 18:20). Second, there is concern about the impact of these medications on cardiac conduction (Ritchier & Norris, JCACAP. 2009; 18:60). Third, of course, is the uncertainty about whether these medications work for patients with AN—for which symptoms, or for which people with AN. In this area there are many case reports suggesting these medications work, but precious few controlled studies in which benefit has been seen. Perhaps the wrong symptoms have been targeted (weight gain rather than cognitive rigidity or anxiety, for example). Or perhaps studies to date have included broad groups of people with AN when only selected subgroups might respond.